Sengstaken-Blakemore tube malposition with esophageal rupture

A 60-year-old man with liver cirrhosis Child's score C secondary to chronic hepatitis C was scheduled for elective ligation of esophageal varices. During endoscopy, four esophageal varices with red whale signs were found. During the ligation procedure, active bleeding was suddenly seen from one of the earlier ligated varix. Unfortunately, further attempted ligations on the bleeding varix failed to secure hemostasis. As a result, SB tube (CLINY, HokkaidO. Japan, type 42, 18 Fr, 6.0-850) was inserted as an emergency measure. When the gastric balloon of the SB tube was inflated, the patient complained of acute sharp pain in his epigastrium. Auscultation failed to confirm the position of gastric balloon and subsequent chest roentgenogram is as shown in Fig. 1a. The ovoid shape gastric balloon was seen above the diaphragm indicating malposition of the balloon. Therefore, immediate deflation and subsequent readjustment of the SB tube position was performed. Patient was seen to have immediate relief of pain, however, another similar episode of severe but persistent epigastric pain occurred the next day. The pain was accompanied with subcutaneous emphysema. Urgent computed tomography of the chest uncovered the cause of pain being due to esophageal rupture and pneumo- mediastinum. (Fig. 1b) Conservative treatment was decided by the family despite a suggestion for emergency surgery. Unfortunately, patient expired one week later after an episode of massive hematemesis in the intensive care unit.